Lunenburg Public Schools

LUNPS CH 385 G

Loxi Jo Calmes Superintendent of Schools

CORI REQUEST FORM The Lunenburg Public Schools has been certified by the Criminal History Systems Board for access to all criminal case data including conviction, non-conviction and pending. As an applicant/employee (volunteer) for the position of ______________________________________ in the Lunenburg Public Schools, I understand that a criminal record check will be conducted for conviction, non-conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge.

____________________________________________ Applicant/Employee/Volunteer Signature

__________________________ Date

(Unless otherwise preempted by law)

Applicant/Employee/Volunteer Information (Please Print) __________________________ Last Name

________________________ First Name

__________________________ Middle Name

__________________________ ________________________ Maiden Name or Alias (If Applicable) Place of Birth

________ /________ /________ Date of Birth

XXX-_________-___________ Social Security Number

________________________ ID Theft Index PIN *

__________________________

Last Six (6) Digits only

(If Applicable)

MOTHER’S MAIDEN NAME

CURRENT AND FORMER ADDRESSES (Please list current address first): _____________________________________________________________________________________ _____________________________________________________________________________________ SEX: _______________

HEIGHT: ____ feet ____ inches

EYE COLOR: ______________

STATE DRIVER’S LICENSE NUMBER: __________________________________________________ (Include state of issue)

THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT-ISSUED PHOTOGRAPHIC IDENTIFICATION*: _____________________________ CORI Authorized Employee/Authorized Designee

REQUESTED BY: _____________________________________________________________________ Signature of CORI Authorized Employee *The CHSB Identity Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft Index PIN Number by the CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are required to be submitted to the CHSB via mail or by fax to 617660-4614.

*A COPY OF THE GOVERNMENT-ISSUED IDENTIFICATION PRESENTED MUST BE ATTACHED TO THIS FORM Form Updated July 2014